Imaging Is Transforming The Practice Of Medicine,
Say Experts From Industry And Academe

But They Also Warn That Rising CostsMean That Demonstrating Value Will Be Crucial

Bethesda, MD -- Medical imaging promises transformative benefits for the practice of medicine. However, the technologies involved are already costly and getting more so, making it crucial to ensure that techniques such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) are used cost-effectively.

That’s the message delivered by two experts, one from industry and one from academe, in an interview with Health Affairs founding editor John Iglehart. The interview was published t oday on the Health Affairs Web site.

The United States has more imaging equipment per capita than other developed countries, says Bill Clarke, who at the time of the interview was executive vice president and chief technology and medical officer at GE Healthcare. But according to Clarke, that does not mean that the U.S. is overspending on imaging. “It is my strong feeling that noninvasive imaging has so revolutionized medical practice by leading to early, more precise, and much less morbid diagnoses that this is a good health care investment,” says Clarke, who now heads Cellectar, a Madison, Wisconsin-based company developing radiopharmaceuticals for cancer therapy.

In 2005, Clarke says, sales of imaging devices in the U.S. totaled $8.1 billion. “This is a significant amount of money, but, to put this in perspective, the estimate for 2005 U.S. sales for all medical devices is $108 billion, and the estimate for pharmaceuticals is in the range of $500 billion.”

E. James Potchen, the University Distinguished Professor and chairman of radiology at Michigan State University, points out that imaging often substitutes for more expensive, more invasive procedures, such as exploratory laparotomy surgeries: “Not long ago we used to do laparotomies to investigate what’s going on in the abdomen. Now, a patient can undergo an outpatient CT scan at far less expense, pain, and inconvenience, and the physician can glean more information than previously possible from an invasive laparotomy.”

Both Potchen and Clarke note that imaging is also used to make sure other treatments are working for particular individuals. “Coronary artery patients are now frequently managed with statins or stents,” says Potchen. “However, whether or not a statin is working effectively to change regional myocardial blood flow is not readily evident without an imaging technique.” And Clarke opines: “I truly believe we will look back in fifteen years and say, I can’t believe we gave people two and a half months of chemotherapy before we looked to see whether or not it was actually helping them.”

Clarke: Pushing The Technologies FurtherMeans Pushing Costs Higher

Nevertheless, imaging technologies don’t come cheap, and “the incremental cost of innovation is getting higher and higher,” according to Clarke. Innovation costs are “increasing because we’re having to push the technology to the outer limits of the physics and engineering sciences,” he says. “Where imaging is going” -- combining the “most difficult aspects” of hardware and software, physics and biochemistry “into what we call molecular imaging -- means that it’s going to be extraordinarily expensive and very difficult to bring that innovation forward.”

To convince payers to fund “what I think is going to be a transformation of medicine, we are simply going to have to do high-quality clinical trials to show the value,” Clarke says. He also endorses the “coverage with evidence development” approach taken by the Centers for Medicare and Medicaid Services with regard to coverage of PET scans. Under this approach, the CMS has agreed to cover certain oncological applications of PET scanning on an interim basis, while “compiling databases of pre- and postscan information and understanding how that affects decision making.”

Clarke calls this “a very creative way to get very solid information about how to use this technology in a large population,” and he says that GE is discussing adopting a similar approach with “one of the big [private] payers.” In general, he says, “I would like to see payers engage in an earlier assessment, an earlier statement of what they would like to see the technology do, and then we need to get to a point where there is a better collegial engagement among purchasers, payers, and technology suppliers -- a clear understanding that we have a shared responsibility or interdependence to assess this technology.”

Potchen: Pay Based On Results,Not Based On Credentials Or Location

Asked by Iglehart how a payer such as the CMS, which has seen costs for radiology services increase dramatically, could ensure that it was getting its money’s worth, Potchen replies that the CMS could pay only for images read by those who had demonstrated a certain level of skill in doing so. He suggests that imaging is uniquely suited to this approach. “With radiology, you’ve got the image after the fact. You can actually see it and see what happened” and measure the value added for each patient.

“Whoever does the job well should be paid,” Potchen says, regardless of whether he or she is a radiologist, a cardiologist, or a member of some other specialty. “The trouble is, [imaging is] so profitable that many people with less-than-adequate knowledge enter the business because there are no restrictions on who does it.” The site of imaging -- inpatient versus outpatient -- should also be immaterial, he adds. “I worry greatly about the current focus on costs of ‘outpatient’ imaging.” Freestanding imaging centers are becoming more prominent in large part because “hospitals are not needed for an awful lot of medical care. If anything, there is too much inpatient capacity because so much care has shifted to ambulatory settings,” Potchen says.

Potchen: For Physicians, Overuse Of Office-Based Imaging Technology Is Tempting

However, Potchen does describe at least one instance in which the site of imaging could affect usage in ways that might be troublesome: “It is so profitable to buy a machine and put it in your office … that it becomes the dominant source of income for many physicians independent of their training. … It’s only human to expect people to want to use equipment they own or are invested in once it is installed in their office,” he observes. “When I was in general practice, I had an x-ray machine. And there’s no question: I would weigh in my mind whether to order an x-ray based upon whether I could do it on the machine in my office. That’s just the way people’s brains function.”

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.